Adverse Impact of Intraoperative Conversion on the Postoperative Course Following Laparoscopic Pancreaticoduodenectomy - Yonsei Medical Journal
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Original Article
Yonsei Med J 2021 Sep;62(9):836-842
https://doi.org/10.3349/ymj.2021.62.9.836 pISSN: 0513-5796 · eISSN: 1976-2437
Adverse Impact of Intraoperative Conversion
on the Postoperative Course Following
Laparoscopic Pancreaticoduodenectomy
Law Cho Kwan Connie1*, Seung Soo Hong2,3*, Incheon Kang4, Seung Yoon Rho5,
Ho Kyoung Hwang2,3, Woo Jung Lee2,3, and Chang Moo Kang2,3
1
Department of General Surgery, Tuen Mun Hospital, Hong Kong SAR, China;
2
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul;
3
Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul;
4
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam;
5
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yongin Severance Hospital, Yongin, Korea.
Purpose: The aim of the current study was to evaluate the adverse clinical impact of intraoperative conversion during laparo-
scopic pancreaticoduodenectomy (LPD).
Materials and Methods: The medical records of patients who underwent pancreaticoduodenectomy (PD) were retrospectively
reviewed. Perioperative clinical variables were compared between patients who underwent converted PD (cPD) and initially
planned open PD (OPD) to investigate the clinical impact and predictive factors of intraoperative conversion during LPD.
Results: A total of 171 patients were included. Among them, 31 patients (19.3%) were found to have intraoperative conversion dur-
ing LPD. Failure of progression due to severe adhesion (12 patients, 7%) and major vessel invasion (7 patients, 4%) were the two
most frequent reasons for conversion. On multivariate analysis, age [Exp(β)=1.044, p=0.044] and pancreatic texture [Expa(β)=2.431,
p=0.039) were found to be independent factors for predicting intraoperative conversion during LPD. In comparative analysis with
the OPD group, the cPD group had a longer operation time (516.8 min vs. 449.9 min, p=0.001), higher rate of postoperative hem-
orrhage (12.1% vs. 0.85%, p=0.008), higher reoperation rate (9.1% vs. 0%, p=0.01), and higher cost (21886.4 USD vs. 17168.9 USD,
p=0.018).
Conclusion: Intraoperative conversion during LPD can have an adverse clinical impact on the postoperative course following
LPD. Appropriate patients selection and improvement of surgical techniques will be crucial for unnecessary intraoperative con-
version and safe LPD.
Key Words: Laparoscopic, pancreaticoduodenectomy, conversion, complication, morbidity
INTRODUCTION ner and Pomp1 reported the first experience of LPD in 1994,
LPD has been regarded as a technically feasible and safe sur-
Laparoscopic pancreaticoduodenectomy (LPD) is a complicat- gery by hepatobiliary and pancreas experts. Recently, more en-
ed and technically demanding surgical procedure. Since Gag- couraging perioperative outcomes of LPD have been reported,
Received: December 17, 2020 Revised: June 24, 2021 Accepted: June 28, 2021
Corresponding author: Chang Moo Kang, MD, PhD, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1
Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea.
Tel: 82-2-2228-2135, Fax: 82-2-313-8289, E-mail: cmkang@yuhs.ac
*Law Cho Kwan Connie and Seung Soo Hong contributed equally to this work.
•The authors have no potential conflicts of interest to disclose.
© Copyright: Yonsei University College of Medicine 2021
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
836 www.eymj.orgLaw Cho Kwan Connie, et al.
compared with open PD (OPD) in treating periampullary tu- erative radiological images. Initial OPD was indicated when
mors.2-6 Recently, the PADULAP randomized control trial dem- patients who refused to have LPD, and they had tumor condi-
onstrated that LPD was associated with a significantly lower tions expected to undergo intraoperative conversion, such as
duration of hospital stay and fewer Clavien-Dindo grade ≥3 com- high risk of tumor invasion around the major vascular struc-
plications, while the resection margin and lymph node harvest tures, and severe intraabdominal adhesion. Intraoperative con-
were comparable.7 The meta-analysis by Chen, et al.8 also showed version was defined as resection that had to be completed by
that LPD had lower transfusion rates, shorter hospital stay, and laparotomy due to technical difficulties or failure to progress
less blood loss. However, in general, the technical feasibility and during LPD. The primary end point of this study was to evalu-
safety of LPD still remain controversial.1,9 ate the perioperative adverse impacts of unplanned intraop-
The inflammatory response secondary to obstructive chol- erative conversion during LPD (cPD) by comparative analysis
angitis and pancreatitis can cause dense adhesion and unex- with initial OPD. The costs associated with unplanned conver-
pected local invasion of the tumor into major vessels, which do sion were also compared.
not favor safe and effective laparoscopic dissection. In addition,
laparoscopic management of the soft remnant pancreas with Data collection
small pancreatic duct is difficult, and these conditions are clin- The patients’ demographic parameters, including age, Ameri-
ically relevant to the development of a postoperative pancreatic can Society of Anesthesiologists (ASA) physical status, body
fistula (POPF).10,11 Indeed, POPF can be a critical complication mass index (BMI), and neoadjuvant therapy, were evaluated.
after pancreatectomy, and it was reported to occur in 3.8%–50% The reoperation rate, readmission rate, postoperative hemor-
of cases in previous meta-analyses.2,3,12-14 Therefore, performing rhage rate, occurrence of delay gastric emptying and POPF (de-
safe LPD to minimize postoperative morbidity is a major con- fined by the International Study Group on Pancreatic Fistula,
cern in reconstruction during LPD. Certain intraoperative cir- ISGPF),22 30-day mortality, and morbidities were assessed. Fur-
cumstances leading to difficult laparoscopic dissection and re- thermore, the transfusion rate, short-term surgical outcome (in-
constructions are considered main reasons for intraoperative cluding transfusion rate), number of retrieved lymph nodes, and
conversion during LPD. R-status of the resection specimen were also evaluated. In addi-
Intraoperative conversion to OPD (converted PD, cPD) is a tion, we examined the reasons for unplanned conversion, such
practical issue for both pancreatic surgeons and patients. PD is as major vascular invasion, failure to progress due to adhesion,
a very complicated surgical procedure, and timely intraopera- easy bleeding tendency, and anatomical anomalies. The Insti-
tive conversion is essential to ensure the safety of LPD. Howev- tutional Review Board of Severance Hospital approved this study
er, several previous reports lacked specific data on intraopera- protocol (IRB No. 4-2018-0863).
tive conversion during LPD.2,3,7,15 According to literature, it is
estimated that the overall conversion rate during LPD is 3.1%– Surgical procedure
24.1% in experienced surgeons.16-21 However, few studies have During LPD, the resection and reconstruction of pancreatico-
investigated the potential impact of intraoperative conversion jejunostomy and hepaticojejunostomy were performed intra-
during LPD on the perioperative clinical course. corporeally. The surgical specimen was retrieved through a mini-
In this study, the perioperative clinical impact of intraoper- laparotomy wound by extending the umbilical port site where
ative conversion during LPD was evaluated, and the potential the duodenojejunostomy was performed.5,23-25
predictive factors for intraoperative conversion were also inves-
tigated. This study is expected to assist in selecting appropriate Statistical analysis
patients to avoid unnecessary intraoperative conversion and Continuous variables were described as the mean±standard de-
achieve the goal of safe LPD. viation, and categorical variables were described as the frequen-
cy (%). Categorical variables were analyzed using the chi-squared
test, and the Student’s t-test was used for continuous variables.
MATERIALS AND METHODS To identify the predictive factors for conversion, multivariate
analyses were performed for different variables using a logistic
Study design regression model. p-valuesConversion in Lap PPPD
formed; 93 patients were male and 78 patients were female, with 42.8%, chi-square, Fisher’s exact test, linear-to-linear associa-
an age range of 61.1±12.0 years. Among them, 155 patients (91%) tion, p=0.013) (Fig. 1).
underwent laparoscopic pylorus-preserving pancreaticoduo- Failure of dissection due to severe adhesion was the most
denectomy (Lap-PPPD), 15 patients (9%) underwent laparo- common reason for conversion during LPD (12 patients, 38.7%),
scopic total pancreatectomies (Lap-TP), and 1 patient (0.6%) followed by suspicion of major vessel [superior mesenteric vein
underwent conventional pancreaticoduodenectomy (Lap-PD). (SMV)/portal vein (PV)] invasion (7 patients, 22.5%) (Table 2).
Only 4 patients (2%) received neoadjuvant therapy before surgery. The main reasons for adhesion were severe inflammation due
Over 70% of the surgeries were performed for malignant dis- to cholangitis, pancreatitis, post neoadjuvant therapy, desmo-
eases. Among these, common bile duct cancer was the most plastic changes surrounding pancreatic head, and direct tumor
common (40 patients, 23%), followed by the ampulla of Vater invasion to major vasculatures. In addition, combined segmen-
cancer (35 patients, 20%). In benign and low-grade malignant tal resection of the colon was necessary in two conversion cases
tumors of the pancreas, intraductal papillary mucinous neo- due to incidental ischemic change of colon following excision
plasms were the most common (26 patients, 15%) (Table 1). or shaving of colonic mesentery for tumor invasion.
Incidence and reasons for intraoperative conversion Predictive factors for intraoperative conversion
during LPD during LPD
Among the 171 attempted LPDs, 31 patients had to convert to In univariate analysis, age (p=0.013), sex (p=0.019), ASA physi-
an open approach during LPD (cPD) and the overall conver- cal status (p=0.039), total bilirubin (p=0.06), size of the pancre-
sion rate was 19.3%. Moreover, the intraoperative conversion atic duct (p=0.047), and pancreatic texture (p=0.015) were as-
rate during LPD was found to be steady over time (range, 13.3%– sociated with conversion during LPD. Diagnosis, neoadjuvant
therapy, BMI, and the size of bile duct were not found to be re-
Table 1. Diagnosis in 171 Laparoscopic Pancreaticoduodenectomy
Cases
lated to conversion (p>0.05) (Table 3). On multivariate analysis,
age {Exp(β)=1.044 [95% confidence interval (CI): 1.001–5.660],
CBD cancer 40 (23)
p=0.044} and pancreatic texture [hard pancreas; Exp(β)=2.431
AoV cancer 35 (20)
(95% CI: 1.044–5.660), p=0.039] were found to be independent
PDAC 29 (17)
IPMN 26 (15) Table 2. Reasons for Conversion during Lap-PD
Metastatic cancer 15 (9)
Reasons for conversion Frequency (%)
NET 14 (8)
Failure to progress due to severe adhesion 12 (39)
AoV adenoma 10 (6)
Suspicious SMV/PV invasion 7 (23)
SPN 6 (4)
Hepatic artery invasion 3 (9.6)
GIST 5 (3)
Combined colon segmental resection 2 (6.4)
Duodenal cancer 4 (0.6)
Internal obesity 2 (6.4)
SCN 2 (1)
Consecutive positive bile duct resection margin 2 (6.4)
Pancreatitis 1 (0.5)
Sustained high pCO2 2 (6.4)
Ganglioma 1 (0.5)
Vascular anomaly (RHA penetrating pancreatic head) 1 (Law Cho Kwan Connie, et al.
Table 3. Clinically Detectable Factors Associated with Converting PD Table 5. Demographics between Converting PD and Initial Open PD
Successful LPD Converting PD Converting PD Initial open PD
p value p value
(n=138) (n=33) (n=33) (n=117)
Age (yr) 59.9±12.1 65.7±10.9 0.013 Age (yr) 65.7±10.9 64.1±9.9 0.392
Sex (male/female) 69/69 24/9 0.019 Sex (male/female) 24/9 71/46 0.227
Diagnosis 1 (benign & Diagnosis 1 (benign &
50/88 9/24 0.609 9/24 9/108 0.017
low-grade/malignant) low-grade/malignant)
Diagnosis 2 (PC/non-PC) 21/117 8/25 0.215 Diagnosis 2 (PC/non-PC) 8/25 52/65 0.044
ASA (1/2) 13/77 0/17 0.039 ASA (1/2/3/4) 0/17/15/1 7/53/51/6 0.882
ASA (3/4) 48/0 15/1 Neo-Tx (no/yes) 32/1 94/23 0.028
Neo-Tx (no/yes) 135/3 32/1 0.579 Total bilirubin 1.4±1.1 1.3±1.2 0.631
Total bilirubin 1.0±0.9 1.41.1 0.076 BMI 23.0±2.5 23.3±3.1 0.744
BMI 23.5±2.9 23.0±2.5 0.431 Operating time 516.8±96.6 449.9±102.9 0.001
BD-size 1.2±1.0 1.3±0.5 0.403 EBL 645.5±559.4 562.1±439.2 0.368
PD-size 3.6±2.2 4.8±3.1 0.047 Transfusion (no/yes) 30/3 102/15 0.764
Pancreatic texture Tumor size 3.4±2.1 2.9±1.6 0.224
96/30 16/14 0.015
(soft/hard) No. of retrieved LNs 12.4±7.5 13.9±8.9 0.380
PD, pancreaticoduodenectomy; LPD, laparoscopic pancreaticoduodenectomy; No. of metastatic LNs 1.9±2.8 1.6±2.9 0.522
PC, pancreatic cancer; ASA, American Society of Anesthesiologists; Neo-Tx, R-status 0/33 4/111 0.575
neoadjuvant treatment; BMI, body mass index; BD-size, bile duct size; PD-
size, pancreatic duct size. PC, pancreatic cancer; ASA, American Society of Anesthesiologists; Neo-Tx,
neoadjuvant treatment; BMI, body mass index; PD, pancreaticoduodenecto-
Table 4. Preoperatively Detectable Clinical Factors Associated with my; EBL, estimated blood loss; LN, lymph nodes.
Hard Remnant Pancreas*
Soft pancreas Hard pancreas Table 6. Adverse Impact of Converting PD on Postoperative Course
p value
(n=112) (n=44) Converting PD Initial open PD
p value
Age (yr) 59.8±12.1 64.1±11.1 0.041 (n=33) (n= 117)
Sex (male/female) 60/52 27/17 0.474 POPF (no/yes) 28/5 98/19 0.463
Diagnosis 1 (benign & POBF (no/yes) 32/1 113/4 1.000
7/34/71 0/7/37 0.024
low-grade/malignant) DGE (no/yes) 26/7 99/18 0.598
Diagnosis 2 (PC/non-PC) 11/101 17/44Conversion in Lap PPPD
three units of packed red blood cells during the postoperative 19.6%, and the morbidity was significantly higher, especially in
period. The other two patients were associated with POPF, which terms of wound infection and longer hospital stay. In contrast,
required interventional angiography and embolization. An- the study by Casillas, et al.28 showed no significant differences in
other patient required reoperation for bleeding from the liver operative time, length of stay, costs, or unexpected remissions.
bed due to detachment of the gallbladder. It was also observed Despite these previous studies, the impact of intraoperative
that emergent diverting loop ileostomy was required in a case conversion during LPD has not been fully investigated. Recent-
of combined colon resection during cPD, and secondary wound ly, Torphy, et al.16 evaluated the clinical impact of conversion to
closure was necessary in one patient. Finally, the medical cost the open approach in their subgroup analysis of minimally in-
was reported to be much higher in the conversion group than vasive PD. They found that 84 robotic pancreaticoduodenecto-
in the initial OPD group {24591443±11903768.2 (￦) [21886.4± mies (RPD, 15.3%) and 823 LPD (25.7%) were converted to OPD.
10594.4 ($)] vs. 19290897.2±5587761.9 (￦) [17168.9±4973.1 ($)]; The LPD patients requiring conversion had no significant dif-
p=0.018} (Table 6). ferences in terms of 90-day mortality compared to those who
completed LPD [odds ratio (OR), 1.48; 95% CI, 0.97–2.24]. For
RPD, while the conversion group showed a 4-fold increase in
DISCUSSION 90-day mortality, no significant difference observed in the con-
version rate over time (p=0.605). Furthermore, the lower the
Since the first LPD was performed in 2008 in our center, the an- volume of minimally invasive PD centers, the higher the con-
nual number of LPD has steadily increased. However, the over- version rate; therefore, the conversion group likely had longer
all conversion rate was estimated to be 19.3% in this study, which operative times and more blood loss. A recent multicenter study29
is similar to that in other studies. To the best of our knowledge, found that elective conversion (e.g., vascular involvement) in
no previous study has directly compared perioperative outcomes minimally invasive distal pancreatectomy for pancreatic ductal
between cPD and initial OPD to investigate the potential clini- adenocarcinoma was associated with comparable short-term
cal impact of cPD. Therefore, this study is thought to be the first oncological outcomes to OPD, while emergency conversions
to investigate the potential adverse impact of conversion during (e.g., bleeding) were associated with worse outcomes over both
LPD. In this study, the conversion group had a longer operating short and long terms. This finding suggests that careful patient
time, higher occurrence of postoperative hemorrhage, higher selection and timely conversion are required to safely conduct
reoperation rate, and consequently higher medical costs. For the minimally invasive pancreatectomy.
patients’ safety during LPD, unnecessary intraoperative con- The current study shows that both age and pancreatic texture
version during LPD should be avoided. This can be ensured by were independent factors that could predict conversion during
careful preoperative patient selection. Therefore, prediction of LPD. Practically, pancreatic texture (hard pancreas) can be pre-
the potential risk of intraoperative conversion before surgery dicted by pancreatic duct size [Exp(β)=1.473 (95% CI: 1.234–
is important. 1.758), pLaw Cho Kwan Connie, et al.
abutted SMV/PV in preoperative CT scan. At present, it is con- a growing number of pancreatic surgeons are performing lap-
sidered impossible to fully predict the possibility of laparoscop- aroscopic or even RPD. A multicenter collaborative study would
ic resection through preoperative image studies. However, the be worthwhile to justify the safety of unplanned conversion to
common point of open conversion cases is that all of the patients open surgery for minimally invasive LPD performed by differ-
have undergone biopsy of the tumor via EUS or endoscopic ret- ent surgeons, and to prevent its adverse effects.
rograde cholangiopancreatography, which can result in tissue
injury and inflammation. The adhesion due to inflammation AUTHOR CONTRIBUTIONS
can mimic tumor invasion to the major vessels. It is recommend-
ed to avoid unnecessary biopsy for lesions requiring surgical Conceptualization: Chang Moo Kang. Data curation: Law Cho Kwan
excision regardless of the biopsy results. Connie and Seung Soo Hong. Formal analysis: Law Cho Kwan Con-
nie and Seung Soo Hong. Investigation: Incheon Kang and Seung
Torphy, et al.16 mainly reported factors associated with a high-
Yoon Rho. Methodology: Incheon Kang and Seung Yoon Rho. Project
er risk of conversion in a minimally invasive group; these includ- administration: Ho Kyoung Hwang and Woo Jung Lee. Resources: Ho
ed the male sex, tumor size >34 mm, and a low PD volume cen- Kyoung Hwang and Woo Jung Lee. Software: Ho Kyoung Hwang and
ter. In this study, the patients’ BMI was around 23 kg/m2, which Woo Jung Lee. Supervision: Chang Moo Kang. Validation: Chang Moo
was not associated with conversion during LPD (23.0±2.5 vs. Kang. Visualization: Law Cho Kwan Connie and Seung Soo Hong.
Writing—original draft: Law Cho Kwan Connie and Seung Soo Hong.
23.3±3.1, p=0.744). However, Cesaretti, et al.31 recommended that
Writing—review & editing: Law Cho Kwan Connie, Seung Soo Hong,
patients with a BMI >40 m/kg2 and locally advanced lesions and Chang Moo Kang. Approval of final manuscript: all authors.
should be reconsidered for LPD. Although the present study
failed to reveal the impact of BMI on intraoperative conversion,
ORCID iDs
according to our experiences, in patients with high BMI, it was
difficult to ensure an operative field, especially when dissecting Law Cho Kwan Connie https://orcid.org/0000-0001-5498-8833
uncinate processes due to the bulky omentum and colon hiding Seung Soo Hong https://orcid.org/0000-0001-9913-8437
in this area, which make the surgery very difficult. In particular, Incheon Kang https://orcid.org/0000-0003-4236-5094
this area, known as the retroperitoneal margin (SMA lateral mar- Seung Yoon Rho https://orcid.org/0000-0002-1265-826X
Ho Kyoung Hwang https://orcid.org/0000-0003-4064-7776
gin), is oncologically very important in patients with pancre- Woo Jung Lee https://orcid.org/0000-0001-9273-261X
atic cancer. Therefore, BMI should also be considered as one of Chang Moo Kang https://orcid.org/0000-0002-5382-4658
the preoperative selection criteria for LPD. In the near future,
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